Rethinking How We Approach Stage 3 Lung Cancer Treatment

October 20, 2020
Victoria Villaflor, MD, Clinical Professor, Director Head and Neck Oncology, City of Hope

As ongoing research continues to unlock the mechanisms of non–small cell lung cancer, it’s becoming increasingly clear that healthcare providers need to start rethinking how treatment is approached—especially for Stage 3 disease.

As ongoing research continues to unlock the mechanisms of non-small cell lung cancer (NSCLC), it’s becoming increasingly clear that we as healthcare providers need to start rethinking how we approach treatment for this disease – especially for Stage 3 NSCLC.

Historically, patients with unresectable Stage 3 NSCLC have had a poor prognosis.

But thanks to treatment advances, survival in unresectable Stage 3A-B-C NSCLC has improved to the point where treating with the intent to cure may be possible for some patients. 5-year overall survival (OS) rate for concurrent chemoradiation therapy (cCRT) has improved from 15 percent in 2010 to 32 percent in 2017.

It’s clear that the current cCRT treatment regimen for Stage 3 NSCLC provides us with a unique opportunity: the chance to treat with curative intent rather than just delaying advancement of disease. Put simply, the treatment goal for these patients should be curative intent. That is why understanding the barriers to this approach and how to address them are crucial in improving survival and outcomes for these patients.

Currently, the recommended treatment by the National Comprehensive Cancer Network (NCCN) is cCRT for the first-line treatment of unresectable Stage 3 NSCLC followed by consolidation immunotherapy. However, despite this recommendation, this treatment remains underutilized in clinical practice—with less than half of patients with Stage 3 NSCLC receiving cCRT.

Accurate Staging Is Key, Especially in Stage 3

Stage 3 NSCLC has a distinct clinical profile from metastatic (Stage 4) disease and has different treatment goals. Approximately 24 percent of patients with NSCLC present with Stage 3 disease, and 82 percent of patients with Stage 3 NSCLC have unresected disease. This includes patients with unresectable disease and patients with resectable disease who declined surgical intervention.

Accurate staging—determining the size, location and spread of the tumor—is critical to determining an appropriate treatment path for each patient. 

If a patient is misdiagnosed, under-staged, or over-staged, they may miss out on management options that have the potential to improve OS or progression-free survival (PFS). When patients with Stage 3 NSCLC are misdiagnosed or upstaged to Stage 4, or metastatic disease, where treatment focuses on palliative care, they miss out on a potentially curative intent approach to treatment. Patients may also misunderstand the difference between Stage 3 and Stage 4 lung cancer, unaware that both stages have different treatment goals and options, so it’s important that we educate patients about proper staging and the wide range of treatment options available for NSCLC. The more they are informed, the more they become active participants in their care.

The Value of Multidisciplinary Care

Working with a multidisciplinary team—including medical and radiation oncologists, thoracic surgeons, pulmonologists, radiologists and pathologists—allows individuals on the team to leverage the insights and expertise of different team members, helping to achieve an accurate diagnosis and the most appropriate treatment. Up to 20 percent of patients presenting with Stage 3 NSCLC to a primary care provider or pulmonologist never received care from other multidisciplinary team members, including an oncologist. Patients seen by the multidisciplinary team are more likely to receive guideline-recommended therapies and experience improved outcomes.

Patients seen by a multidisciplinary team, including use of a tumor board during diagnosis and treatment planning, are also more likely to receive this recommended cCRT treatment. Tumor board participation can have a positive influence in increasing treatment guideline adherence and accelerating treatment initiation, ultimately potentially improving patient outcomes. Taking a multidisciplinary approach to coordinating care can also help healthcare providers adhere to guidelines, but there are deviations from those guidelines in special cases and additional testing may be indicated.

Proactively Managing Patient Concerns

As healthcare providers, we need to maintain an open dialogue and listen to our patients’ therapeutic goals and concerns. While it is common for newly diagnosed patients to have preconceived notions and fears about cCRT side effects, it’s important for them to know that techniques used to manage side effects of chemoradiation treatment have evolved tremendously and there are interventions that can be used to help manage and mitigate these potential adverse effects. For example, intensity-modulated radiation therapy (IMRT), an advanced form of radiotherapy, is more targeted and less toxic, potentially decreasing side effects like pneumonitis and esophagitis in some patients.

A Reason to Instill Hope

While a Stage 3 lung cancer diagnosis can be frightening and overwhelming, it is crucial for patients not to give up hope. By rethinking the way we treat patients, we can change their perceptions and, in some cases, help them understand that treatment with curative intent may be a possibility for some.

For more information on treatment options for unresectable Stage 3 non-small cell lung cancer, visit www.azioinpractice.com.


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